Abstract
Patients with atrial fibrillation (AF) are at increased risk for coronary artery disease (CAD). After percutaneous coronary intervention (PCI), the antithrombotic therapy consists of a combination of anticoagulant and antiplatelet agents to reduce the ischemic and thromboembolic risk, at the cost of increased bleeding events. In the past few years, several randomized clinical trials involving over 12,000 patients have been conducted to compare the safety of vitamin K antagonist (VKA) and direct-acting oral anticoagulants (DOACs) in association with a single- or double-antiplatelet agent, in the so-called dual- (DAT) or triple-antithrombotic therapy (TAT). These studies and several meta-analyses showed a consistent benefit for reducing bleeding events of DAT over TAT and of DOAC over VKA, without concerns about ischemic endpoints, except for a trend for increased stent thrombosis risk. The present paper examines current international guidelines’ recommendations and reviews clinical trials, meta-analyses, and observational studies conducted on AF patients treated with DAT or TAT after PCI for acute coronary syndromes.
Highlights
The incidence of atrial fibrillation (AF), the most common sustained arrhythmia, is increasing as a consequence of the aging population and wide-spreading risk factors [1,2]
The 2020 European Society of Cardiology (ESC) guidelines on AF [4] recommend that in patients with AF and ACS undergoing an uncomplicated percutaneous coronary intervention (PCI), a triple-antithrombotic therapy (TAT) with aspirin, clopidogrel, and an oral anticoagulant (OAC) should be given during the peri-PCI period, up to 1 wk
Several randomized clinical trials involving approximately 12,000 patients demonstrated that dual-antithrombotic therapy (DAT) significantly reduces bleeding events compared to TAT
Summary
The incidence of atrial fibrillation (AF), the most common sustained arrhythmia, is increasing as a consequence of the aging population and wide-spreading risk factors [1,2]. About 15% of patients with AF may require percutaneous coronary interventions (PCIs) with stent implantation to treat obstructive CAD [6]. After PCI, these patients would require an antithrombotic therapy combining oral anticoagulant (OAC) and antiplatelet agents, aimed to decrease both the risk of thromboembolism due to AF and the risk of acute ischemic events related to thrombosis of coronary stents [7,8]. The benefits of this strategy may be counterbalanced by the increasing risk of bleeding [9]. The most promising approach to reduce bleeding events appears to be represented by the choice of a direct anticoagulant agent (DOAC) rather than vitamin K antagonists (VKAs) and to reduce the length of TAT or to avoid it
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